Disclosure. Disclosure. Disclosure. Course Outline. Objectives. A Touch of Sugar : Controlling Hyperglycemia in Acute Care Settings 7/25/2013

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1 47 th Annual Meeting August 2-4, 2013 Orlando, FL A Touch of Sugar : Controlling Hyperglycemia in Acute Care Settings Kevin Forbush, Pharm. D Central Maine Medical Center Lewiston, Maine Disclosure I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation 2 Disclosure I do have a vested interest in or affiliation with the following companies or organizations Speaker s Board Novo Nordisk Sanofi Disclosure As in any situation, clinical judgment supersedes these recommendations and each patient's therapeutic needs must be assessed on a case by case basis. 3 4 Objectives Upon completion of this activity, the participant should be able to: Apply evidence based practice to diabetic patients across transitions of care including from home to hospital and hospital to discharge. Initiate appropriate therapy in the hospitalized hyperglycemic patient. Discuss optimal diabetic management when transitioning between critical care and step down care. Describe issues surrounding orders to resume home insulin pumps 5 Course Outline Introduction: Basal:Bolus regimens General floor treatment recommendations Patient case Critical care treatment guidelines 2013 SCCM Insulin Infusion Guidelines Conversion from IV to Subcutaneous insulin Patient case Clinical scenarios Steroid induced hyperglycemia Insulin pumps 6 1

2 Sliding Scale Insulin ADA: Prolonged therapy with sliding scale insulin (SSI) as the sole regimen is ineffective in the majority of patients, increases risk of both hypoglycemia and hyperglycemia Basal Bolus Regimens: Plan ahead! Goal is to change the way we think about glycemic control Think prospectively!!! How can insulin be dosed prospectively, effectively? What about hypoglycemia? POOR PLANNING? ADA Standards of Medical Care of Diabetes Evidence Base Relative lack of data/guidelines for inpatients Most data in critical care IV Infusion General population overlooked, except RABBIT trials Recommendations based on clinical experience expert consensus Key References Moghissi ES, et al. AACE/ADA Consensus Statement on Inpatient Glycemic Control. Endocr Pract May Jun;15(4): Umpierrez GE, et al. Randomized Study of Basal Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT2). Diabetes Care Sep;30(9): Inzucchi SE. Management of hyperglycemia in the hospital setting. N Engl J Med 355: , Jacobi J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med Dec;40(12): Society of Hospital Medicine: Quality Improvement Resource Room. Improving Glycemic Control, Preventing Hypoglycemia, and Optimizing Care of the Inpatient with Hyperglycemia and Diabetes. 10 Basal Bolus Correction Theory Goal Mimic natural physiology of insulin release How? Mix & match different insulin formulations Maximize PK differences to achieve goal 11 Glossary Basal insulin Mimics fasting insulin release in non DM patient. Long acting analogs recommended Bolus insulin Mimics insulin release in response to nutrition (aka: nutritional or prandial insulin) Correction scale Accounts for under dosing of insulin or increased nutritional intake. Used in conjunction with scheduled administrations of insulin. Analogous to sliding scale insulin 12 2

3 The Physiological Insulin Profile Insulin (mu/l) Short-lived, rapidly generated prandial insulin peaks Normal free insulin levels from genuine data (mean) Low, steady, basal insulin profile Breakfast Lunch Dinner Adapted from Polonsky, et al Reprinted with permission from the American Diabetes Association's Clinical Education Program "Insulin Therapy for the 21st Century." Basal/Bolus Treatment Program Blood Glucose Targets Plasma insulin Breakfast Lunch Dinner SAA SAA SAA SAA: Short Acting Analog LAA: Long Acting Analog LAA Critical Care Less than 180 mg/dl Greater than 70 mg/dl Greater than 100 mg/dl in neuro cases Optimal BG range undefined Non critically ill Pre meal: less than 140 mg/dl Random: less than 180 mg/dl Reassess treatment for BG less than 100 mg/dl Modify for BG less than 70 mg/dl 4:00 8:00 12:00 16:00 20:00 24:00 4:00 8:00 Moghissi ES, et al. Endocr Pract May-Jun;15(4): Jacobi J, et al. Crit Care Med Dec;40(12): Patient Case: MS HPI: 68 yo female. Admitted for Community Acquired Pneumonia w/ SIRS. Fluid responsive hypotension/tachycardia. Placed on ceftriaxone and azithromycin for CAP. Diabetic diet ordered. Admitted to general floor. PMH: T2DM x 7 years Hyperlipidemia Osteoarthritis Obesity 17 Patient case: MS Patient data 68 yo female, Wt: 108 kg A1c 2 months ago: 9.1% Home meds: APAP 650 mg po four times daily Aspirin EC 81 mg po qday Atorvastatin 20 mg po qday Metformin 1000 mg po BID Sitagliptin 50 mg po BID Glyburide 5 mg po BID 3

4 Patient case: MS BG data: Admission 2300: 273 mg/dl Day #1 0500: 227 mg/dl Day #1 0900: 287 mg/dl How will we manage MS s hyperglycemia? Inpatient Medications APAP 650 mg po four times daily Aspirin EC 81 mg po qday Atorvastatin 20 mg po qday Ceftriaxaone 2 gm IV q24h Azithromycin 500 mg IV q24h Initial Treatment Plans Discontinue oral agents Many contraindications for inpatients Not specifically studied for inpatients May cloud the picture of control Weight Based Dosing 1. Calculate initial estimated Total Daily Dose of Insulin (TDDI) based on patient factors 2. Divide the TDDI into a 50:50 ratio between Basal:Bolus insulin 1. Give basal once daily (at bedtime) 2. Split bolus according to intake status Choose bolus insulin to max PK advantage 3. Select a Correction Scale based on estimated TDDI Clement S, Braithwaite SS, Magee MF, et al. Diabetes Care. 27: ;2004 Inzucchi SE.. N Engl J Med 355: , Clement S, Braithwaite SS, Magee MF, et al. Diabetes Care. 27: ;2004 Umpierrez GE, et al. Diabetes Care. 30: , Step 1: Estimating TDDI Type 1 Use therapy as at home MUST have basal insulin (or constant IV infusion) to prevent ketosis May hold or cut mealtime doses if intake is poor If on pump, calculate 24hr basal requirement Discontinue pump Order basal requirement as long acting analog. Start now If therapy unknown, Basal: units/kg/day Bolus: units/kg/dose Correction Scale Inzucchi SE.. N Engl J Med 355: ,

5 Step 1: Estimating TDDI Type 2 Conservative starting point for most: 0.4 to 0.5 units/kg/day High risk for hypoglycemia (Very lean, significant renal/hepatic failure, hemodialysis): 0.3 units/kg/day Overweight/known insulin resistance/high dose steroid tx units/kg/day Split TDDI into a 50:50 ratio of basal:bolus insulin Consider 30: 70 ratio for steroid induced hyperglycemia Clement S, Braithwaite SS, Magee MF, et al. Diabetes Care. 27: ;2004 Step 2: Ordering Insulin Basal Basal insulin (Long acting insulin) 50% of TDDI calculation Long acting analogs (Detemir/Glargine) Preferred by ADA/AACE Usually dosed at bedtime NPH Requires q12hr dosing Higher risk of hypoglycemia Less expensive Adjust dose based on AM FBG If using BID dosing adjust AM dose on pre dinner BG Adjust by 10 to 20% based on degree of poor control Umpierrez GE, et al. Diabetes Care. 30: , Step 2: Ordering Insulin Bolus Insulin For regular diet: Use 50% of TDDI split w/meals (or 0.05 to 0.1 units/kg/meal) Use short acting analogs most physiologic Insulin Requirement During Continuous Dextrose, TPN or Enteral Feedings = Regular = Glargine = Continuous feed For continuous supplemental feeds (TF/TPN) Use 50% of TDDI split q6h (or 0.05 to 0.1 units/kg/dose) Use regular insulin PK properties For NPO No bolus insulin necessary Continue basal orders Insulin Requirement During Continuous Dextrose, TPN or Enteral Feedings Tube Feeds Off = Regular = Glargine = Continuous feed Step 2: Ordering Insulin Adjustment of Bolus doses Adjust by 1 2 units per dose for: Pre meal BG greater than 140 mg/dl Degree and uniformity determines adjustment May need larger adjustments, use correction scale to guide Work backwards i.e. Lunch BG indicative of Breakfast insulin dose, etc

6 Step 3: Correction Scale NOT sliding scale being combined with Basal (& Bolus) Accounts for underestimation of TDDI, intake, and insulin resistance Select scale based off TDDI calculation Pre set scales available Step 3: Correction Scale For NPO, Still select based on Total DDI Can use regular q6h or SAA q4h For patient w/ continuous feed, Use regular insulin (same times as bolus) For patient w/diet, Use SAA Uses a lower HS scale Prevention of nocturnal hypo Basal usually dosed at this time Society of Hospital Medicine: Quality Improvement Resource Room. Step 3: Correction Insulin Algorithm based on TDDI example Medium Dose Analog Insulin Algorithm (requires 40 to 80 units per day) Premeal BG Extra Insulin Extra Insulin HS AC unit 0 unit units 2 unit units 3 units units 4 units 350 or greater 9 units 5 unit Preventing Hypoglycemia Orders and protocols for treatment of low levels Attach to every patient receiving insulin Utilizing HOLD orders Not expected to eat or TF/TPN stopped Managing orders to account for decreased insulin need Decreasing steroid doses Resolving stress related hyperglycemia RABBIT 2: Glycemic Control With Basal Bolus vs Sliding Scale Insulin N=130 insulin-naïve hospitalized nonsurgical patients with T2DM n=9 with BG >240 mg/dl Switched from 220 Sliding-scale sliding-scale to 260 basal-bolus insulin 200 * * * Basal-bolus Admit Admit Days of therapy *P<.01; P<.05; Long-acting insulin (glargine) once daily + short-acting insulin (glulisine) before meals, total dose 0.4 unit/kg (BG mg/dl) or 0.5 unit/kg (BG mg/dl). Blood glucose (mg/dl) Patient case: MS Patient data 68 yo female, Wt: 108 kg A1c 2 months ago: 9.1% SrCr: 1.1 (mild elevation) Ate breakfast. Good appetite since antibiotoics/fluid given. Umpierrez GE et al. Diabetes Care. 2007;30:

7 Patient case: MS Step 1: Discontinue oral agents Step 2: Calculate TDDI TDDI = 0.5 units/kg/day * 108 kg = 54 units/day Step 3: Split into 50:50 ratio Basal insulin (detemir/glargine): 27 units at bedtime Consider giving partial dose now Nutritional insulin (aspart/lispro/glulisine): 9 units w/ meals Medium dose correction scale Step 4: Daily follow up Adjust based on BG data Patient case: MS Step 5: Discharge planning Start early A1c 9.1% despite 3 oral meds Opportunity to talk to patient about starting insulin as outpatient it is indicated per guidelines Allow patient to self administer under direct supervision (if allowed per policy) to address potential fears Assess diabetic education level and address knowledge gaps? CDE consult Communicate with PCP about starting basal insulin therapy Start home regimen 1 to 2 days prior to discharge if possible and monitor. ICU Critical Care Guidelines HPI: 63 yo male. Septic shock, secondary to bowel perforation. S/P washout and repair. Admitted to ICU post op. Adequate IVF resuscitation w/ NS. Currently on norepinephrine at 8 mcg/min, Goal MAP 65, At goal MAP, currently weaning. NPO. PMH: CAD HTN T2DM Patient data 63 yo male, Wt: 120 kg A1c 1 month ago: 8.2% Home meds: Aspirin EC 81 mg po qday Metoprolol 50 mg po BID Lisinopril 5 mg po qday Atorvastatin 20 mg po qday Metformin 500 mg po BID Glyburide 5 mg po BID Labs: Na, K, Cl, Mag, Ca CO2 all WNL. On replacement protocols for K, Mag. SrCr 2.4, BUN 32 (baseline SrCr 1 mg/dl) Blood Glucose over past 12 hours with CMP q6h: 0100: 220 mg/dl 0700: 325 mg/dl Problems: 1. Sepsis 2. Hypotension 3. Acute Kidney Injury 4. Hyperglycemia 7

8 How should we manage AM s hyperglycemia? SCCM 2012 Hyperglycemia Guidelines: Key Points (i) 1. Hyperglycemia is associated with poor patient outcomes (mortality) 2. Use insulin infusion therapies in ICU to target: a) BGs less than 150 mg/dl (absolutely less than 180) b) Low rate of hyperglycemia a) Defined as BG less than 70 mg/dl, b) In neuro cases, less than 100 mg/dl) 3. Automatic triggers for protocol initiation a) i.e. Initiate protocol if BG values over 150 mg/dl twice in 12 hours Jacobi J, et al. Crit Care Med Dec;40(12): SCCM 2012 Hyperglycemia Guidelines: Key Points (ii) 4. Monitor BG every 1 to 2 hours 5. Consider whole blood sampling (not finger sticks) for some patients: a) Shock b) Vasopressor tx c) Severe peripheral edema 6. Use 1 unit/ml concentration using regular insulin a) i.e. Regular insulin 100 units in 100 ml NS b) Prime tubing with 20 ml of infusion solution SCCM 2012 Hyperglycemia Guidelines: Key Points (iii) 7. Use subcutaneous insulin sparingly in critically ill a) Rapidly changing clinical status a) Nutrition b) Elimination b) Poor perfusion to subcutaneous tissue 8. Develop glucometrics to monitor protocol a) Mean/Median BG levels b) Time in goal range (% of readings) c) Hypoglycemic events (suggest any severe hypoglycemia has RCA done) d) Error reporting IIP Selection Considerations Achieve glycemic control in a short timeframe Minimal hypoglycemia Low operator error rate Minimal nursing time required Applicable to wide array of patient populations 1 IIP across different ICUs (think of float nurses!) 1 Standard DKA protocol Wilson M, et al. Diabetes Care Apr;30(4): Newton CA, et al. J Hosp Med Oct;5(8): Consider a protocol with a multiplier scheme opposed to a fixed dose scheme Accounts for rate of change and current infusion rate Consider computerguided algorithms $$$ Glucommander EndoTool SCCM 2012 Hyperglycemia Guidelines: Key Points (iv) 9. Once stable, transition to subcutaneous Basal Bolus regimen a) No planned interruption of nutrition b) Edema resolved c) Off Vasopressors d) BG in range on a stable infusion rate 10. Calculate Basal Bolus dose based off of the infusion rate 48 8

9 When? Indications for IV insulin must be resolved Rate should be stable (4 to 6 hours) BG should be in goal range Who? All T1DM must be converted to a regimen which includes basal insulin T2DM on a rate less than 0.5 ml/hr May not need to be converted Dose Calculation How? 1. Calculate Total Daily Dose (TDD) of insulin based on mean infusion rate Use safety factor of 60 to 80% of 24hr requirement TDD = (Mean rate * 24 hours * 0.6 or 0.8) O Malley CW et al. J Hosp Med Sep;3(5 Suppl): Basal Dosing 2. If patient is fasting (no substantial nutrition i.e. less than 120 gm of IV dextrose): TDD = Basal dose Use Long acting analog 3. If patient getting nutrition: Basal dose = 50% of TDD calculation Use long acting analog Nutritional Dosing 2. If feeding to be started: Use 10 to 20% of basal dose as nutritional dose w/ each meal or q6h (if on tube feed/tpn) Hold orders If not expected to eat/enteral feed not tolerated/tpn dc d BG less than 80 Use short acting analog for meals Use regular insulin for supplemental feed 3. If being fed: Use 50% of TDD and divide w/meals or q6h Hold orders Insulin selection Correction Scale Order correction scale Use same formulation and frequency as nutritional insulin if starting feed If not starting feed, use SAA q4h or regular insulin q6h Order scale that fits with TDD Discontinuing Infusion Stop infusion 2 hours after administration of Long Acting Analog Onset of action of LAA insulin ~ 2 hr Frequently overlooked Pharmacists can help! If patient must transfer NOW: May overlap by only 1 hr if short acting/regular + long acting analog given Give 10% of basal dose as short acting/regular

10 Hospital Day Doing great, off pressors x 48 hrs Labs normalized, baseline Remains NPO, but will start trickle feed this PM Looking to transfer to Med/Surg floor Need to convert IV insulin for transfer BGs ranging from mg/dl overnight Hourly insulin rate 3 units/hr +/ 1 unit over past 12 hours D5W1/2NS + KCL 20 meq running at 75 ml/hr for past 36 hours How should we convert AM s insulin regimen? Step 1: Calculate estimated TDD TDD = (3 unit/hr *24 hr *60%) = 43.2 units/day Step 2: Order basal insulin Insulin detemir /glargine: 45 units qam. Start NOW Alternatively on conversion day: Give half NOW (20 units), half at bedtime (25 units) Start full dose at bedtime tomorrow 58 Step 3: Order nutritional insulin Use 10 to 20% of basal dose Order: 5 units regular insulin q6h, Start when tube feed at goal Hold for: BG less than 80 mg/dl Tube feed off or not to goal Step 4: Order correction scale based on TDD Order: Medium dose correction scale, regular insulin q6h Step 5: Discontinue infusion Order: Stop insulin infusion 2 hours after insulin detemir/glargine given Step 6: Hypoglycemia protocol (auto) Step 7: Follow up and adjust daily

11 Steroid Induced Hyperglycemia Mainly a post prandial effect Attenuates release of insulin by pancreas Recommend: Increase TDDI calculation to unit/kg/day Split ratio 30:70, basal:bolus As steroid dose tapered down, taper down bolus insulin. Insulin Pumps Policy varies by institution Not addressed in guidelines CMHC system official policy Not allowed (much like home BIPAP, CPAP devices) Can not be assured of service record and proper functioning Rapidly changing patient mental status Nurses are not trained on every pump May restart immediately prior to discharge Actual Practice Key References Moghissi ES, et al. AACE/ADA Consensus Statement on Inpatient Glycemic Control. Endocr Pract May Jun;15(4): Umpierrez GE, et al. Randomized Study of Basal Bolus Insulin Therapy in the Inpatient Management of Patients With Type 2 Diabetes (RABBIT2). Diabetes Care Sep;30(9): Inzucchi SE. Management of hyperglycemia in the hospital setting. N Engl J Med 355: , Jacobi J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med Dec;40(12): Society of Hospital Medicine: Quality Improvement Resource Room. Improving Glycemic Control, Preventing Hypoglycemia, and Optimizing Care of the Inpatient with Hyperglycemia and Diabetes